EDITOR,—Richard Hobbs fails adequately to address two reasons, which he himself cites, for the increase in emergency admission—namely, raised expectations of general practitioners and worries over litigation.1 It would be difficult to argue that the rise in emergency admissions in recent years bears no relation to the increased demand for home visits by general practitioners, among other factors, as general practitioners pass on some of this workload to hospital doctors. In addition, faced with an increasingly litigious public, general practitioners are more often (not surprisingly) playing safe and admitting patients if in doubt.

While sympathising with the increased pressures that general practitioners are facing, we must also recognise some of the more disturbing factors that are fuelling this problem. In some situations it seems that fundholding general practitioners, who have a financial incentive to avoid paying for outpatient appointments, admit patients with semiurgent problems as emergencies. In addition, a minority of general practitioners have unacceptably high referral rates; Hobbs's justification that a threefold to fourfold variation in referral rates is acceptable because the variation in prescribing is greater seems suspect, even if allowance is made for demographic factors. Furthermore, Hobbs's assertion that hospital doctors, not general practitioners, decide on admission would probably be disputed by most junior doctors, who are wary of upsetting the general practitioners whom their consultants (and future referees) serve. Besides, many doctors would concede that most verbal referrals, if suitably phrased by the referring doctor, will be accepted whether from outside or within the hospital.

The health service will clearly not be able to cope with the rise in emergency admissions at the current rate without further compromising patients' care and increasing pressure on junior doctors. I believe that many junior doctors disagree with Hobbs's apparent view that the trend is not inappropriate and think that more rational referral policies for emergency admissions are required. If we want to avoid our health service turning into the type of expensive, demand led service seen on the Continent then general practitioners will have to take some responsibility for curbing this phenomenon.